Cytopathology Review Fang Fan, Ivan Damjanov
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Cervical and Vaginal CytologyCHAPTER 1

Fang Fan
 
Questions
Q1. Which of the following guidelines should be followed in order to obtain an ideal Pap smear specimen?
  1. A lubricated speculum is favored over a non-lubricated speculum
  2. The sample should be obtained after the application of acetic acid
  3. Excess mucus or other discharge should be retained for examination
  4. An optimal specimen includes cells exclusively from the ectocervix
  5. Two weeks after the last menstrual period (LMP) is the preferred examination time
Q2. According to the specimen adequacy criteria in the 2014 Bethesda System, which of the following Pap smear specimens is considered unsatisfactory for evaluation?
  1. Thin-preparatory smear containing approximately 6000 squamous cells
  2. Conventional smear containing approximately 6000 squamous cells
  3. Smear without endocervical cells
  4. Smear with 50% of epithelial cells obscured by inflammation
  5. Smear with 50% of epithelial cells obscured by drying artifact
Q3. How many well-visualized squamous cells must be present on a liquid-based Pap slide from a healthy woman so that the specimen would be considered to be satisfactory for evaluation?
  1. 1,000
  2. 2,500
  3. 5,000
  4. 8,000
  5. 10,000
Q4. When estimating cellularity on a Pap smear slide, what type of cells should be included in the evaluation?
  1. Metaplastic squamous cells
  2. Squamous cells obscured by neutrophils
  3. Endocervical cells
  4. Endometrial cells
  5. Histiocytes
Q5. Pap smear specimens with less than 5,000 squamous cells may still be considered adequate in which of the following conditions?
  1. Women younger than 21 years
  2. Women aged 21–29 years2
  3. Women who are pregnant
  4. Women who received radiation therapy for cervical cancer
  5. Women who are on oral contraceptives
Q6. The Pap smear from a 38-year-old woman showed cohesive flat sheets of cells with large nuclei, pale chromatin, abundant cytoplasm and prominent nucleoli. Occasional mitoses were seen. These features are characteristic of which of the following?
  1. Atrophy
  2. Repair
  3. Atypical endocervical cells, not otherwise specified
  4. Endocervical adenocarcinoma
  5. Squamous cell carcinoma
Q7. Which of the following cytologic features is characteristic of radiation changes seen in a Pap smear?
  1. High nuclear-to-cytoplasmic ratio
  2. Abundant isolated cells
  3. Cytoplasmic vacuolization and polychromasia
  4. Frequent mitoses
  5. Coarsely granular and hyperchromatic chromatin
Q8. Women born to mothers who took diethylstilbestrol (DES) during pregnancy would most likely show what type of changes in their vaginal smear specimens?
  1. Shift in vaginal flora
  2. Low-grade squamous intraepithelial lesion (LSIL)
  3. High-grade squamous intraepithelial lesion (HSIL)
  4. Atrophic vaginitis
  5. Presence of glandular cells
Q9. HPV infection is established in which layer of the squamous epithelium?
  1. Anucleated surface keratin layer
  2. Parakeratotic surface squamous cells
  3. Superficial squamous cells
  4. Intermediate squamous cells
  5. Basal squamous cells
Q10. Which of the following statements is true regarding cervical oncogenesis and the genome of human papillomavirus (HPV)?
  1. The E1 and E2 are most responsible for the cervical oncogenesis
  2. The E3 and E4 are the principal components of the HPV vaccines
  3. L1 binds to the retinoblastoma tumor suppression protein pRB and abolishes cell-cycle arrest
  4. E6 binds to p53 and results in blocking of apoptosis
  5. E7 binds to p16 and results in proliferation of cells
Q11. Which of the following statements is true regarding HPV?
  1. HPV is a small RNA virus
  2. HPV 6, 11 is the most common subtypes detected in cervical cancer
  3. Only a minority of HPV infections persist and lead to cancer
  4. Koilocytes are an artifact of fixation and not related to HPV infection
  5. Serology is an accurate way to detect HPV infection
Q12. Which of the following is the most important cytomorphologic feature for high-grade squamous intraepithelial lesion (HSIL)?
  1. Prominent nucleoli
  2. Syncytial cell growth3
  3. Prominent cytoplasmic vacuoles
  4. Large cell size
  5. High nuclear-to-cytoplasm ratio
Q13. Which of the following statements is true about the follow-up management after a Pap smear interpretation of low-grade squamous intraepithelial lesion (LSIL)?
  1. Adolescents with LSIL are managed less aggressively
  2. Postmenopausal women with LSIL are managed more aggressively
  3. Pregnant women with LSIL are managed more aggressively
  4. HPV testing is recommended for premenopausal women with LSIL
  5. Diagnostic excisional procedures are routinely used in women with LSIL
Q14. A 30-year-old woman had a routine Pap smear. The smear showed cells of squamous metaplasia with some degree of nuclear atypia, concerning but not definitive for the diagnosis of high-grade dysplasia. How these cells are best classified?
  1. Atypical squamous cells of undetermined significance (ASCUS)
  2. Atypical squamous cells cannot exclude HSIL (ASC-H)
  3. Low-grade squamous intraepithelial lesion (LSIL)
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Squamous cell carcinoma
Q15. A 25-year-old pregnant woman had a Pap smear which was interpreted as high-grade squamous intraepithelial lesion (HSIL). Which of the following statements is correct for pregnant women with HSIL?
  1. Colposcopy during pregnancy is not recommended
  2. Diagnostic excisional procedure should only be performed postpartum
  3. Colposcopy and repeat Pap testing should be performed immediately postpartum
  4. Biopsy of lesions suspicious for CIN 2 or CIN 3, if feasible
  5. Endocervical curettage (ECC) should be always performed
Q16. Which of the following is a specific cytomorphologic feature for squamous intraepithelial lesion (SIL)?
  1. Perinuclear halos
  2. Nuclear enlargement
  3. Prominent nucleoli
  4. Hyperchromasia and irregular nuclear membrane
  5. Finely granular chromatin
Q17. Which HPV subtype accounts for the majority of cervical squamous cell carcinoma worldwide?
  1. HPV 6
  2. HPV 11
  3. HPV 16
  4. HPV 18
  5. HPV 31
Q18. Which of the following cytologic features may help distinguish squamous cell carcinoma (SCC) from high-grade squamous intraepithelial lesion (HSIL)?
  1. Tumor diathesis
  2. High nuclear-to-cytoplasmic ratio
  3. Abundant keratinizing cytoplasm
  4. Hyperchromasia
  5. Irregular cell shapes
Q19. Prominent macronucleoli are cytologic features of cells classified under which one of the following diagnoses?
  1. Low-grade squamous intraepithelial lesion (LSIL) cells4
  2. High-grade squamous intraepithelial lesion (HSIL) cells
  3. Parabasal squamous cells in atrophy
  4. Squamous cells in atypical repair
  5. Benign endometrial cells
Q20. “Feathering” is a term used to describe Pap smear findings in which of the following entities?
  1. Tubal metaplasia
  2. Endocervical adenocarcinoma in-situ (AIS)
  3. Exfoliated endometrial cells
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Invasive adenocarcinoma
Q21. Which of the following features is more typical of neoplastic endocervical cells (AGUS or AIS) than reactive/reparative endocervical cells?
  1. Flat sheet arrangement
  2. Prominent nucleoli
  3. Marked variation in nuclear size
  4. Elongated and hyperchromatic nuclei
  5. Presence of mitosis
Q22. When differentiating endocervical adenocarcinoma from endometrial adenocarcinoma, which of the following features favor endometrial rather than endocervical adenocarcinoma?
  1. Prominent nucleoli
  2. Mitoses
  3. Tumor diathesis
  4. Intracytoplasmic neutrophils
  5. Abundant cytoplasm
Q23. Which of the following represents the most common metastatic tumor to cervix?
  1. Metastatic breast carcinoma
  2. Metastatic melanoma
  3. Metastatic rectal carcinoma
  4. Metastatic ovarian carcinoma
  5. Metastatic urothelial carcinoma
Q24. A 30-year-old woman had a Pap test showing high-grade intraepithelial lesion at the time of her annual gynecologic examination. She underwent a colposcopic examination. A biopsy of the cervix showed moderate squamous dysplasia (CIN 2). What is the most appropriate management recommendation for this woman?
  1. Repeat the Pap test in 6 months
  2. Perform the loop electrosurgical excision procedure (LEEP)
  3. High-risk HPV test
  4. Hysterectomy
  5. Endocervical curettage
Q25. What is the most common anatomic location of cervical squamous intraepithelial neoplastic (CIN) lesions?
  1. Lateral side of ectocervix
  2. The transformation zone/squamocolumnar junction
  3. Lower end of the endocervical canal
  4. Upper end of the endocervical canal
  5. Vaginal fornix
Q26. Which of the following statements is true about the currently used HPV vaccine Gardasil?
  1. The vaccine covers all high-risk HPV subtypes
  2. Women are not protected if they have been infected by the same HPV types prior to vaccination
  3. The vaccine is approved for use in sexually active women of all ages5
  4. The vaccine contains inactivated live viruses subtypes 16 and 18
  5. The vaccine is given orally in three doses over a 6-month period
Q27. Dark blue or purple calcific spheres with concentric laminations are rarely encountered in Pap smears. What is the clinical significance of the finding?
  1. It represents a rare contaminant of no clinical significance
  2. It represents a rare microorganism
  3. It may be associated with endometriosis
  4. It may be associated with an endocrine disorder
  5. It may be associated with an ovarian neoplasm
Q28. What is the recommended initial workup for women with a Pap smear diagnosis of atypical endometrial cells?
  1. Reflex high-risk HPV testing
  2. Immediate repeat Pap smear
  3. Colposcopic examination
  4. Endometrial and endocervical sampling
  5. Simple hysterectomy
Q29. Hyperchromatic crowded groups (HCGs) seen in a Pap smear under low power are helpful diagnostic features for which of the following conditions or diseases?
  1. Atypical squamous cells of undetermined significance (ASCUS)
  2. Low-grade squamous intraepithelial lesion (LSIL)
  3. High-grade squamous intraepithelial lesion (HSIL)
  4. Repair
  5. Radiation changes
Q30. When differentiating endocervical adenocarcinoma from endometrial adenocarcinoma, which positive immunohistochemical stain favors the diagnosis of endocervical adenocarcinoma?
  1. Estrogen receptor (ER)
  2. Vimentin
  3. p16
  4. Pancytokeratin
  5. Beta-catenin
Q31. According to the current (published in 2012) joint recommendations of the American cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, cervical cancer screening for women in the general population should begin at what age?
  1. The age of sexual initiation
  2. The age of 1st pregnancy
  3. Age 21
  4. Age 30
  5. Age 35
Q32. A 35-year-old woman presents for her well woman exam. Which of the following statements is true regarding her cervical cancer screening according to the current ASCCP screening guideline?
  1. She can be screened every year with Pap smear alone
  2. She can be screened every year with HPV test alone
  3. She can be screened every year with Pap smear and HPV co-testing
  4. She can be screened every three years with Pap smear and HPV co-testing
  5. She can be screened every five years with Pap smear and HPV co-testing
Q33. For women aged 21–29 years, what is the current recommended cervical cancer screening guideline?
  1. No screening
  2. Cytology alone every year
  3. Cytology alone every 3 years6
  4. Cytology and HPV co-testing every 3 years
  5. Cytology and HPV co-testing every 5 years
Q34. Which of the following is an acceptable management choice for women >age 30, who are cytology negative but HPV positive?
  1. Repeat cytology in 6 months
  2. Repeat cytology in 12 months
  3. Repeat co-testing in 6 months
  4. Repeat co-testing in 12 months
  5. Refer for immediate colposcopy
Q35. A Pap smear was performed on a 42-year-old woman and reported as “atypical endocervical cells NOS”. What is the appropriate management for her?
  1. Reflex HPV testing
  2. Repeat cytology in 12 months
  3. Endocervical sampling
  4. Colposcopy
  5. Colposcopy with endocervical sampling and endometrial sampling
Q36. In which of the following populations that cervical cancer screening is not necessary?
  1. Women who are vaccinated against HPV
  2. Women who are postmenopausal
  3. Women who are younger than 21 years
  4. Women who underwent total hysterectomy five years ago and had CIN II
  5. Women older than 65 years with a history of CIN III 10 years ago
Q37. A 68 year-old woman has a recent Pap smear reported as ASCUS and the reflex HPV test is negative. Her two previous Pap smears were negative. Which of the following statements is correct regarding her management?
  1. She is allowed to exit from screening because she is over 65 years
  2. She should be referred to colposcopy
  3. She should be further tested for HPV16 and HPV18
  4. She should repeat screening in 3 years
  5. She should repeat screening in 1 year
Q38. These cells (arrow) in a ThinPrep smear represent which of the following?
  1. Metaplastic squamous cells
  2. Superficial squamous cells
  3. Intermediate squamous cells
  4. Endocervical cells
  5. Endometrial cells
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Q39. The group of epithelial cells shown here represents which of the following?
  1. Atypical squamous cells of undetermined significance (ASC-US)
  2. High-grade squamous intraepithelial lesion (HSIL)
  3. Endocervical adenocarcinoma in-situ (AIS)
  4. Parabasal squamous cells in atrophy
  5. Repair
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Q40. The arrow points to a group of squamous cells showing signs of which process?
  1. Hyperkeratosis
  2. Parakeratosis
  3. Atrophy
  4. Repair
  5. Metaplasia
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Q41. This group of cells (arrow) represents which of the following?
  1. Benign endocervical cells with tubal metaplasia
  2. Atypical endocervical cells, not otherwise specified (AGUS, NOS)
  3. Benign endometrial cells
  4. Atypical endometrial cells
  5. Adenocarcinoma
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Q42. This Pap smear was obtained from a 32-year-old woman, on day 6 of menstrual cycle. What are the cells indicated by the arrow?
  1. High-grade squamous intraepithelial lesion (HSIL)
  2. Small cell carcinoma
  3. Squamous cell carcinoma
  4. Benign endometrial cells
  5. Benign endocervical cells
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Q43. This Pap-smear obtained from a 64-year-old woman is best interpreted as which of the following?
  1. Benign endometrial cells
  2. Lymphoid aggregates indicative of follicular cervicitis
  3. High-grade squamous intraepithelial lesion (HSIL)
  4. Endometrial adenocarcinoma
  5. Lymphoma
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Q44. The cells seen here are covered by coccobacilli due to a shift in vaginal flora. Which term is best used to denote these cells?
  1. Cornflake
  2. Koilocytes
  3. Navicular cells
  4. Clue cells
  5. Blue blobs
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Q45. This cervical vaginal smear was obtained from a 35-year-old woman with a frothy vaginal discharge. These findings are most consistent with an infection with which one of the following pathogens?
  1. Herpes simplex virus
  2. Candida albicans
  3. Human papilloma virus
  4. Gardnerella vaginalis
  5. Trichomonas vaginalis
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Q46. This vaginal smear was obtained from a 55 year-old diabetic woman complaining of vaginal pruritus and white discharge. These findings are most consistent with an infection with which one of the following pathogens?
  1. Herpes simplex virus
  2. Candida albicans
  3. Human papilloma virus
  4. Gardnerella vaginalis
  5. Trichomonas vaginalis
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Q47. This vaginal smear was obtained from a 23-year-old woman complaining of occasional genital discomfort and dyspareunia. These cytologic findings are most consistent with an infection with which one of the following pathogens?
  1. Herpes simplex virus
  2. Candida albicans
  3. Human papilloma virus
  4. Gardnerella vaginalis
  5. Trichomonas vaginalis
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Q48. The cells in the center of this image represent which of the following?
  1. Normal intermediate squamous cells
  2. Atypical squamous cells of undetermined significance (ASCUS)
  3. Low-grade squamous intraepithelial lesion (LSIL)
  4. Normal endocervical cells
  5. Normal endometrial cells
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Q49. A 28-year-old woman presented for routine Pap smear. The cytology findings are shown here. What is the most appropriate next step management for this patient?
  1. Routine Pap smear in one year
  2. HPV testing on the Pap smear specimen
  3. Colposcopic examination
  4. Cervical loop electrosurgical excision procedure (LEEP)
  5. Endometrial sampling
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Q50. This slide shows a Pap smear from a 23-year-old woman. What is the proper follow-up management for women with such findings?
  1. Send the specimen for HPV DNA testing
  2. Repeat Pap smear in one year
  3. Repeat Pap smear in six month
  4. Colposcopic examination should be performed
  5. Offer HPV vaccine immunization
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Q51. What is the correct interpretation of this Pap smear from a 40-year-old woman?
  1. Low-grade squamous intraepithelial lesion (LSIL)
  2. High-grade squamous intraepithelial lesion (HSIL)
  3. Atrophy
  4. Repair
  5. Endocervical adenocarcinoma in-situ (AIS)
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Q52. What is the correct interpretation of this Pap smear from a 34-year-old woman?
  1. Atypical squamous cell of uncertain significance (ASCUS)
  2. Low-grade squamous intraepithelial lesion (LSIL)
  3. High-grade squamous intraepithelial lesion (HSIL)
  4. Atrophy
  5. Repair
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Q53. This cervical smear was obtained from a 23-year-old sexually active nulliparous woman. What is the correct diagnosis?
  1. Atypical glandular cells of undetermined significance (AGUS)
  2. Low-grade squamous intraepithelial lesion (LSIL)
  3. High-grade squamous intraepithelial lesion (HSIL)
  4. Atypical squamous cells of undetermined significance (ASCUS)
  5. Benign reactive squamous cells
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Q54. A 42-year-old woman, with no significant history had a routine Pap smear which is shown here. What is the interpretation of these findings?
  1. Low-grade squamous intraepithelial lesion (LSIL)
  2. Endocervical adenocarcinoma
  3. Squamous cell carcinoma
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Atypical endocervical cells, favor neoplastic
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Q55. A 55-year-old woman, had a routine Pap smear. There were no prior Pap smears on file. What is the correct interpretation of the cells in this Pap smear?
  1. Reactive endocervical cells
  2. Atypical endocervical cells
  3. Atypical endometrial cells
  4. Atypical squamous cells of undetermined significance (ASCUS)
  5. High-grade squamous intraepithelial lesion (HSIL)
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Q56. What is the correct diagnosis of this Pap smear obtained from a 62-year-old woman?
  1. Low-grade squamous intraepithelial lesion (LSIL)
  2. Atrophy
  3. Squamous cell carcinoma
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Trichomonas infection
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Q57. The cell shown here (arrow) is most commonly associated with which of the following?
  1. Intrauterine device (IUD)
  2. Herpes virus infection
  3. Human papilloma virus infection
  4. Oral contraceptive use
  5. Postpartum state
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Q58. What is the correct interpretation of this Pap-smear from a 22-year-old pregnant woman?
  1. Normal
  2. Atypical squamous cells of undetermined significance (ASCUS)
  3. Atypical squamous cells cannot exclude HSIL (ASC-H)
  4. Low-grade squamous intraepithelial lesion (LSIL)
  5. High-grade squamous intraepithelial lesion (HSIL)
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Q59. This Pap smear was obtained from a 45-year-old woman. What is the correct interpretation?
  1. Repair
  2. Tubal metaplasia
  3. Atypical squamous cells cannot exclude HSIL (ASC-H)
  4. Endocervical adenocarcinoma in-situ (AIS)
  5. Exfoliated endometrial cells
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Q60. A 50-year-old woman presented with abnormal bleeding. A Pap smear was obtained and is shown here. What is the correct interpretation?
  1. High-grade squamous intraepithelial lesion (HSIL)
  2. Endocervical adenocarcinoma in-situ (AIS)
  3. Reactive endocervical cells
  4. Benign endometrial cells
  5. Endometrial adenocarcinoma
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Q61. The abnormal finding shown in this Pap smear (arrow) is most frequently associated with which of the following?
  1. HPV infection
  2. Trichomonas vaginalis infection
  3. Intrauterine device (IUD) use
  4. Pregnancy
  5. Diabetes
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Q62. This Pap smear was obtained as a routine Pap smear from a 24-year-old woman. What is your interpretation?
  1. Negative for intraepithelial lesion or malignancy
  2. Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H)
  3. Low-grade squamous intraepithelial lesion (LSIL)
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Repair
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Q63. What is the best interpretation for this Pap smear obtained from a 55-year-old woman?
  1. Atrophy
  2. Atypical squamous cells of undetermined significance (ASCUS)
  3. Atypical squamous cells cannot exclude HSIL (ASC-H)
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Atypical endometrial cells
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Q64. What is the correct diagnosis of these cells from a Pap smear obtained from a 42-year-old woman?
  1. Benign endometrial cells
  2. Lymphoid aggregate indicative of follicular cervicitis
  3. Reparative squamous cells
  4. Reactive endocervical cells
  5. Parabasal squamous cells
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Q65. A 72-year-old woman who had a clinical history of rectal adenocarcinoma presented with vaginal bleeding. The vaginal smear is shown here. What is the most likely diagnosis?
  1. Endocervical adenocarcinoma
  2. Endometrial adenocarcinoma
  3. Squamous cell carcinoma
  4. Metastatic adenocarcinoma
  5. Lymphoma
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Q66. What is the correct diagnosis of this Pap smear?
  1. High-grade squamous intraepithelial lesion (HSIL)
  2. Squamous cell carcinoma
  3. Endometrial adenocarcinoma
  4. Metastatic carcinoma
  5. Melanoma
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Q67. What is the proper name for the most prominent cells in this Pap smear obtained from a 35-year-old woman?
  1. Koilocytes
  2. Navicular cells
  3. Clue cells
  4. Corn flake cells
  5. Tadpole cells
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Q68. What is the correct interpretation of this Pap smear obtained from a 54-year-old woman?
  1. Radiation changes
  2. Cytomegalovirus-associated changes
  3. Intrauterine device (IUD) effect
  4. Adenocarcinoma
  5. Squamous cell carcinoma
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Q69. What are these cells in a Pap smear obtained from a 47-year-old woman?
  1. Endometrial cell
  2. Parabasal squamous cells
  3. Lymphocytes
  4. High-grade squamous intraepithelial lesion (HSIL) cells
  5. Low-grade squamous intraepithelial lesion (LSIL) cells
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Q70. What is the correct diagnosis for this Pap smear obtained from a 54-year-old woman?
  1. Parakeratosis
  2. Atrophic vaginitis
  3. Atypical squamous cells of undetermined significance (ASCUS)
  4. Atypical squamous cells cannot exclude HSIL (ASC-H)
  5. Squamous cell carcinoma (SCC)
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Q71. What is the best designation for the cells indicated by the arrow?
  1. Normal
  2. Atypical squamous cells of undetermined significance (ASCUS)
  3. Atypical squamous cells cannot exclude HSIL (ASC-H)
  4. Low-grade squamous intraepithelial lesion (LSIL)
  5. Repair
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Q72. This Pap smear was obtained from a 46-year-old nulliparous woman. This hyperchromatic crowded group (HCG) is most consistent with which diagnosis?
  1. Endometrial adenocarcinoma
  2. Low-grade squamous intraepithelial lesion (LSIL)
  3. High-grade squamous intraepithelial lesion (HSIL)
  4. Parabasal squamous cells in atrophy
  5. Benign endometrial cells
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Q73. This Pap smear was obtained from a 62-year-old woman. What is the most appropriate interpretation of this epithelial group?
  1. Benign endometrial cells
  2. Parabasal squamous cells in atrophy
  3. Endometrial adenocarcinoma
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Endocervical adenocarcinoma
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Q74. This Pap smear was obtained from a 36-year-old woman during her routine annual examination. What is the correct diagnosis?
  1. Benign endometrial cells
  2. Parabasal squamous cells in atrophy
  3. Endometrial adenocarcinoma
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Endocervical adenocarcinoma
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Q75. What is the best designation for this cell group in a Pap smear from a 50-year-old woman?
  1. High-grade squamous intraepithelial lesion (HSIL)
  2. Endometrial adenocarcinoma
  3. Parabasal squamous cells in atrophy
  4. Reactive endocervical cells
  5. Endocervical adenocarcinoma in-situ (AIS)
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Q76. A 43-year-old woman presents for routine screening. What is the diagnosis for her Pap smear?
  1. Reactive endocervical cells
  2. Endocervical adenocarcinoma
  3. Repair
  4. Radiation changes
  5. Intrauterine device (IUD) effect
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Q77. What is the correct interpretation of this Pap smear?
  1. Atypical squamous cells of undetermined significance (ASCUS)
  2. Atypical endocervical cells
  3. Atypical endometrial cells
  4. Repair
  5. Atrophy
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Q78. A 55-year-old woman had hysterectomy for endometrial adenocarcinoma a year ago. This is her follow up vaginal smear. What is the correct diagnosis?
  1. Recurrent endometrial adenocarcinoma
  2. Atypical squamous cells of undetermined significance (ASCUS)
  3. Atypical squamous cells cannot exclude HSIL (ASC-H)
  4. Radiation changes
  5. Benign glandular cells status post hysterectomy
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Q79. This Pap smear was obtained from a 47-year-old woman. What is the correct diagnosis?
  1. Metastatic adenocarcinoma
  2. Lymphoma
  3. Small cell carcinoma
  4. Leiomyosarcoma
  5. Melanoma
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Q80. This is a representative image of a Pap smear obtained from a 38 year-old woman who presented for routine cytology screening. What is the most appropriate follow-up step for her?
  1. Repeat Pap smear in 1 year
  2. Repeat Pap smear in 3 years
  3. Send the specimen for reflex HPV testing
  4. Refer the patient to colposcopy
  5. Refer the patient to endometrial sampling
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Q81. This is a representative image of a Pap smear obtained from a 56-year-old woman who presented with vaginal bleeding. A cellblock was prepared from the Thin-Prep vial. Immunohistochemical stains showed that these hyperchromatic spindle cells were negative for Pan-cytokeratin, desmin and caldesmon; and positive for WT-1 and CD10. What is the correct diagnosis?
  1. Carcinosarcoma
  2. Leiomyosarcoma
  3. Endometrial stromal sarcoma
  4. Metastatic renal cell carcinoma
  5. Lymphagiomyosarcoma
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Q82. This cell group was identified on a Pap smear of a 42-year-old woman. The follow-up colposcopy and endocervical sampling revealed no lesion. What is the appropriate next step in managing this patient?
  1. Repeat Pap and HPV contesting in 3 years
  2. Repeat Pap and HPV contesting in 5 years
  3. Endometrial sampling
  4. Diagnostic excision procedure
  5. Simply hysterectomy
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Q83. This Pap smear was obtained from a 56-year-old woman who had a clinical history of pancreatic adenocarcinoma. Which of the following cytologic features in this image supports a diagnosis of metastatic adenocarcinoma over a primary endometrial/endocervical adenocarcinoma?
  1. High nuclear to cytoplasmic ratio
  2. Cytoplasmic vacuoles
  3. Prominent nucleoli
  4. Normal squamous cells
  5. Clean background
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Q84. What is the correct interpretation of this cell group on a Pap smear?
  1. Benign endometrial cells
  2. Benign endocervical cells with tubal metaplasia
  3. Endocervical adenocarcinoma in-situ (AIS)
  4. Endometrial adenocarcinoma
  5. High-grade squamous intraepithelial lesion (HSIL)
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Q85. This is a representative image of a Pap smear from a 49-year-old woman. What is the correct diagnosis?
  1. Atypical squamous cells of undetermined significance (ASCUS)
  2. Atypical squamous cells cannot exclude HSIL (ASC-H)
  3. Low-grade squamous intraepithelial lesion (LSIL)
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Squamous cell carcinoma
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Q86. This image was taken from a Pap smear of a 32-year-old woman. A cellblock was prepared from this sample. Which of the following immunohistochemical stains is most helpful in confirming the diagnosis?
  1. Pan-cytokeratin
  2. p16
  3. Synaptophysin
  4. CD45
  5. S-100
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Q87. This image was taken from a Pap smear of a 39-year-old woman. What is the follow-up recommendation for her regarding cervical cancer screening?
  1. Repeat Pap in three years
  2. Reflex HPV testing on the current specimen
  3. Immediate colposcopy with endocervical sampling
  4. Diagnostic excision
  5. Endocervical and endometrial sampling
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Q88. This Pap smear image was taken from a 45-year-old woman on her well-woman examination. What is the correct interpretation?
  1. Hodgkin lymphoma
  2. Non-Hodgkin lymphoma
  3. Follicular cervicitis
  4. Small cell carcinoma
  5. High-grade squamous intraepithelial lesion
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Q89. This image was taken from a 68-year-old woman who had a history of left mastectomy and sentinel lymph node biopsy. Immunohistochemical stain on the cellblock from this Pap smear demonstrated these cells negative for p63, p16, SOX-10, and e-cadherin. What is the most likely diagnosis?
  1. Metastatic melanoma
  2. Metastatic lobular carcinoma of the breast
  3. Metastatic small cell carcinoma
  4. Endometrial adenocarcinoma
  5. High-grade squamous intraepithelial lesion (HSIL)
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24
Q90. This group of cells is seen on a Pap smear of a 38-year-old woman. Which of the following clinical history is critical to know when interpreting this Pap smear?
  1. Abnormal bleeding
  2. Pregnant
  3. On oral contraceptives
  4. Intrauterine device (IUD) use
  5. HPV test result
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Q91. Identification of these structures on a Pap smear indicates which of the following diagnosis?
  1. Parasitic infection
  2. Viral infection
  3. IUD use
  4. Squamous cell carcinoma
  5. Ovarian neoplasm
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Q92. This Pap smear was obtained from a 46-year-old woman. What is the best interpretation?
  1. Benign metaplastic cells
  2. Reactive endocervical cells
  3. LSIL
  4. ASC-H
  5. ASCUS
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25
Q93. This image is a representative field of a Pap smear from a 64-year-old woman. What is the correct interpretation?
  1. Atrophy
  2. Trichomonas infection
  3. ASCUS
  4. Atypical endometrial cells
  5. HSIL
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Q94. This image was taken from a Pap smear of a 72-year-old woman. What is the correct interpretation?
  1. Squamous cell carcinoma
  2. Endometrial adenocarcinoma
  3. Metastatic adenocarcinoma
  4. Radiation changes
  5. Viral infection
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Q95. This image was taken from a Pap smear of a 54-year-old woman who presented with irregular bleeding. The HPV co-testing is positive for HPV 16. What is the correct diagnosis?
  1. Benign endometrial cells
  2. Benign/reactive endocervical cells
  3. Endometrial adenocarcinoma
  4. Endocervical adenocarcinoma
  5. High-grade squamous intraepithelial lesion (HSIL)
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26
Q96. This image was taken from a Pap smear of a 32-year-old pregnant woman. Which of the following steps is the preferred management?
  1. Observation only
  2. Reflex HPV testing with HPV genotyping
  3. Immediate colposcopic examination
  4. Immediate endocervical sampling
  5. Immediate loop electrosurgical excision
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27
 
Answers
1. E.
Note: As established by the Clinical and Laboratory Standards Institute, the following guidelines should be followed to obtain an ideal Pap smear:
  • The examination should be scheduled 2 weeks after the first day of the last menstrual period. It is preferable to avoid examination during menses.
  • Specimens should be obtained after insertion of a non-lubricated speculum. Excess mucus or other discharge should be removed gently.
  • The sample should be obtained before the application of acetic acid or Lugol iodine.
  • An optimal sample should include cells from the ectocervix and endocervix.
2. B.
Note: In the 2014 Bethesda System, the “satisfactory for evaluation category” implies that a satisfactory squamous component is present (the minimum number of squamous cells for adequacy for liquid-based smears is 5000 and for conventional smears is 8000–12,000). The specimen is considered unsatisfactory for evaluation if obscuring elements cover more than 75% of epithelial cells. A smear without endocervical cells is not considered unsatisfactory; instead, the absence of an endocervical or transformation zone is mentioned as a “quality indicator” in the report.
3. C.
Note: In the 2014 Bethesda System, the “satisfactory for evaluation category” implies that a satisfactory squamous component is present (the minimum number of squamous cells for adequacy for liquid-based smears is 5000 and for conventional smears is 8,000–12,000).
4. A.
Note: The cellularity evaluation should include well-visualized squamous cells and metaplastic squamous cells. Squamous cells completely obscured by inflammatory cells, glandular cells and histiocytes are not included in the evaluation.
5. D.
Note: The 2014 Bethesda System clearly states that woman who has had chemotherapy, radiation therapy, or postmenopausal with atrophic changes may have samples with less than 5,000 cells and still be considered adequate at the discretion of the laboratory. However, samples with less than 2,000 cells should be considered unsatisfactory in these circumstances.
6. B.
Note: The features described are characteristic of repair. Parabasal squamous cells in atrophy have moderate amount of cytoplasm without prominent nucleoli. Atypical endocervical cells have elongated hyperchromatic nuclei and scant cytoplasm. Endocervical adenocarcinoma contains crowded groups of cells or cells forming microacini or rosettes. Squamous cell carcinoma has necrotic debris, abundant singly dispersed malignant cells with coarsely granular chromatin.
7. C.
Note: Characteristic cytomorphologic features of radiation changes include normal N/C ratio, finely granular chromatin, cytoplasmic vacuolization and polychromatia, and multinucleation.
8. E.
Note: About one third of the DES-daughters develop vaginal adenosis, characterized by the formation of glands in the vaginal mucosa. Most of them are benign. Clear-cell carcinoma of the vagina is the least common but the worst complication of in-utero DES exposure.
9. E.
Note: HPV infection is established in the basal layers of the squamous epithelium. As the epithelium matures toward the surface, gene amplification and viral assembly occur, leading to eventual viral release.
10. D.
Note: The E6 and E7 genes are most responsible for the cervical oncogenesis. E6 binds to p53 and E7 binds to pRB thus leading to host cell transformation. L1 is the major viral capsid protein and is the principal component of the HPV vaccines.
11. C.
Note: HPV is a circular double-stranded DNA virus. HPV 16 is the most common subtype detected in cervical cancer. HPV 6,11 are low-risk HPV viruses. Koilocytes are associated with HPV virus infection. Only 50–60% of infected women have circulating HPV antibodies.
12. E.
Note: Characteristic cytomorphologic features of HSIL include high N/C ration, cells of parabasal-size, marked irregular nuclear membrane, coarse chromatin and hyperchromasia.28
13. A.
Note: Except for adolescents and postmenopausal women, colposcopy is recommended for women with LSIL. HPV testing and routine diagnostic excisional procedures are not recommended for women with LSIL.
14. B.
Note: ASC-H is used when metaplastic squamous cells or atrophic squamous epithelium show certain degree of atypia, impossible to be distinguished from HSIL.
15. D.
Note: Colposcopy should be performed by an experienced physician on all women found to have HSIL in a Pap smear. Any lesion suspicious for CIN 2, CIN3 or cancer should be biopsied if feasible. ECC is generally unacceptable during pregnancy. If invasive cancer is suspected, a diagnostic excisional procedure is acceptable. If CIN 2,3 is not found histologically, reevaluation with colposcopy and a Pap smear is recommended no sooner than 6 weeks postpartum.
16. D.
Note: There are nonspecific perinuclear halos including inflammatory halos and glycogen halos. Irregular nuclear membrane and hyperchromasia are the most important diagnostic features for LSIL even in the absence of nuclear enlargement. Prominent nucleoli are a feature of reactive squamous cells or invasive squamous cell carcinoma.
17. C.
Note: HPV 16 accounts for about 50–60% of all cervical squamous cell carcinomas worldwide. HPV 18 accounts for an additional 10–15% of all cases.
18. A.
Note: Prominent macronucleoli and tumor diathesis are the main cytologic features that help distinguish SCC from HSIL. Tumor diathesis refers to the granular debris in the background from lysed blood and cell fragments. It is a feature of invasive carcinoma in Pap smears.
19. D.
Note: Prominent macronucleolus is a cytologic feature of repair, invasive squamous cell carcinoma and adenocarcinoma.
20. B.
Note: In AIS, hyperchromatic columnar cells arrange in rosettes or strips, or splaying out around the edges of the cell groups and sheets, so-called “feathering”.
21. D.
Note: Elongated and dark nuclei are typical of AGUS or AIS. Flat sheet arrangement, prominent nucleoli and marked variation in size are features of reactive/reparative processes. Mitoses may occur in both neoplastic and reactive endocervical cells.
22. D.
Note: Tumor diathesis can be seen in all invasive carcinomas. Prominent nucleolus, mitosis and abundant cytoplasm are features of both endocervical and endometrial adenocarcinomas. However, intracytoplasmic neutrophils are more commonly seen in endometrial adenocarcinoma cells.
23. D.
24. B.
Note: Loop electrosurgical excision procedure (LEEP) is currently the treatment of choice for CIN 2 and CIN3.
25. B.
Note: CIN lesions typically begin at the squamocolumnar junction because the HPV virus preferentially infects the cells of this transformation zone.
26. B.
Note: The currently used HPV vaccine (Gardasil) is produced by the recombinant DNA procedure, and it does not contain live virus particles. It is given in the form of three injections over a six-month period. Women are not protected if they have been infected with that HPV type(s) prior to vaccination. The vaccine is approved for use in females 9–26 years of age. It contains epitopes of most common carcinogenic HPV subtypes 6,11,16,18.
27. E.
Note: Psammoma bodies are extremely rarely found in Pap smears. Their presence should prompt a search for ovarian/tubal neoplasms.
28. D.
Note: The recommended initial workup for women with a Pap smear diagnosis of atypical endometrial cells is endometrial and endocervical sampling. If no endometrial pathology is found, colposcopy is recommended.
29. C.
Note: HCGs include the following differential diagnoses: HSIL (carcinoma in-situ, CIS), AIS, atrophy and benign endometrial cells. Examination of the cell group arrangement, cells around the edge of the group, nuclear features, and background cells will help making a correct diagnosis.
30. C.
Note: Pancytokeratin is positive in both adenocarcinomas. Endometrial adenocarcinomas are usually ER+, vimentin+, and beta-catenin+.
31. C.
Note: Cervical cancer screening for average-risk women should begin at age 21 regardless of the age of sexual initiation.29
32. E.
Note: The current ASCCP cervical cancer screening guideline has the following options for women between 30–65 years of age: Every 3 years with Pap smear alone (acceptable) or every 5 years with Pap smear and HPV co-testing (preferred). Additionally, she can also be screened every 3 years with HPV test alone (the Roche Cobas HPV test only).
33. C.
Note: According to the current ASCCP screening guideline, women aged 21–29 years should be screened with cytology alone every 3 years. Primary screening HPV test and/or HPV co-test should not be performed in women younger than 30 years. Annual screening is not recommended.
34. D.
Note: For women ≥age 30, who are cytology negative but HPV positive, they can be managed by (1) repeat co-testing in 12 months; or (2) immediate HPV genotyping for HPV 16 and HPV 18. If HPV 16 or HPV 18 positive, refer to colposcopy; if HPV16 and HPV 18 negative, repeat co-testing in 12 months.
35. E.
Note: The recommended management for AGUS NOS (except atypical endometrial cells) is colposcopy with endocervical sampling and endometrial sampling (for women >35 years).
36. C.
Note: No screening is necessary for women younger than 21 years because cervical cancer rate is very low in this age group and screening has not be shown to be effective for this age group. Woman who are vaccinated against HPV and women who are postmenopausal should follow age-specific screening guideline. Women older than 65 years and have adequate negative prior screening results (three consecutive negative cytology or two consecutive negative co-testing in prior 10 years) no longer need screening. However, women with a history of CIN II, CIN III or AIS should continue screening for a total of 20 years after spontaneous regression or appropriate management of these lesions, even if they are older than 65 or have had hysterectomy.
37. E.
Note: For women older than 65 years and considering exiting screening, HPV negative ASCUS is considered abnormal. Repeat screening with cytology alone or co-testing in 1 year is recommended. Three consecutive negative cytology or two consecutive negative co-testing are needed before she exits screening.
38. A.
Note: The cells are arranged in flat sheets, they have moderate amounts of dense cytoplasm, and show mild variation in nuclear size with slightly irregular nuclear contours. They differ from superficial and intermediate squamous cells; they have less cytoplasm than these cells and it is less dense. Endocervical cells are usually arranged in a honeycomb or picket-fence pattern and have mucinous cytoplasm. Endometrial cells usually form small three-dimensional groups.
39. D.
Note: This is a typical atrophic smear showing a large group of squamous cells arranged in cohesive flowing sheets. Nuclei are bland with smooth nuclear membrane. Prominent nucleoli (as seen in repair) are not present.
40. B.
Note: Parakeratosis is characterized by keratinized cells with elongated pyknotic nuclei and dense orangeophilic cytoplasm. This benign reactive change is usually associated with chronic irritation. There is no nuclear atypia. Hyperkeratosis refers to anucleated mature, keratinized squamous cells which may appear isolated or are arranged into plaques.
41. A.
Note: These tightly packed cells are columnar with abundant cytoplasm and cilia on their apical surface. The appearance of cilia is a feature of tubal metaplasia, a benign change of the endocervical glandular cells.
42. D.
Note: Spontaneously exfoliated endometrial cells may be seen in Pap smears taken during the first 12 days of menstrual cycle. They form small three-dimensional groups composed of cells with scant cytoplasm and nuclei that are the same size as that of intermediate squamous cells. Their nuclear contours are often irregular.
43. B.
Note: This group of cells is composed of aggregates of lymphocytes. Small mature lymphocytes predominate, but there are also a few large lymphocytes and tangible-body macrophages (arrow). The latter cells are very useful clues for the diagnosis of chronic follicular cervicitis.
44. D.
Note: The term clue cell is used for squamous cells covered by adherent small coccobacilli, most frequently Gardnerella vaginalis. Lactobacilli, which form the normal vaginal flora are absent. The term cornflake refers to the refractile brown artifact seen on superficial squamous cells due to air-bubbles trapped under the cover slip. Koilocytes are cells showing cytopathic changes due to human papilloma virus (HPV)- cells have a large cytoplasmic cavity with a condensed sharply defined inner edge. Nuclei are often enlarged showing hyperchromasia and irregular nuclear contour. Binucleation is common. Navicular cells are squamous cells with abundant pale-yellow colored cytoplasm representing glycogen. They are more abundant during pregnancy. Blue blobs are dark, round, amorphous masses seen in atrophic smears. They represent either condensed mucus or degenerated bare nuclei.30
45. E.
Note: This smear contains Trichomonas vaginalis, an ovoid, pear-shaped protozoon (arrow) measuring 1–2 mm in longest diameter. It has a nucleus, scant cytoplasm, and also flagellae which are, however, not seen readily in Pap smears. The squamous cells show reactive changes such as slight nuclear enlargement and an indistinct perinuclear halo.
46. B.
Note: This smear shows pseudohyphae and yeast forms of Candida albicans. Tangles of pseudohyphae admixed with yeast forms are colloquially described as “spaghetti and meatballs”. Sometimes the squamous cells appear in linear arrays as if skewered by the pseudohyphae (popularly described as “shish-kebabs”).
47. A.
Note: Multinucleated cells with ground-glass chromatin, like the ones shown here (arrow), are diagnostic of herpes simplex virus infection.
48. D.
Note: The cells form a flat sheet and at the periphery are columnar in shape with abundant mucinous cytoplasm, which is characteristic of endocervical cells. Squamous cells (normal, ASCUS and LSIL) do not form such glandular structures. Endometrial cells are smaller and form three-dimensional groups.
49. B.
Note: The cells shown in this Pap smear have mildly enlarged nuclei, irregular nuclear membrane and mild hyperchromasia, which are all features of ASCUS. According to the current recommended management guideline developed by American Society for Colposcopy and Cervical Pathology (ASCCP) this woman should undergo HPV testing. If HPV test is positive, the patient is referred to colposcopy; if HPV test is negative, the patient should return to screening in 3 years.
50. D.
Note: The cells shown here are koilocytes and represent LSIL. Colposcopic examination is the proper follow-up and should be included in the management of all patients with LSIL.
51. B.
Note: The cells have hyperchromatic nuclei with irregular nuclear membrane and high nuclear to cytoplasmic ratio (N/C ratio). High N/C ratio is one of the key features of HSIL.
52. E.
Note: The cells form a flat sheet with streaming (so called “school of fish”). The nuclei contain prominent nucleoli, a feature of reactive squamous cells.
53. B.
Note: This smear shows koilocytes, which are characteristic of low-grade intraepithelial lesions (LSIL). The cells have moderately enlarged nuclei and characteristic peri-nuclear halo with a condensed rim.
54. E.
Note: The cells are columnar in shape, have elongated and hyperchromatic nuclei, characteristic of atypical endocervical cells. These features are not characteristic of a squamous intraepithelial lesion (LSIL or HSIL). Endocervical adenocarcinoma cells have abnormal glandular arrangement (micro-acini, rosettes) and prominent nucleoli. Non-keratinizing squamous cell carcinoma cells have scant and dense cytoplasm, coarse chromatin and prominent nucleoli.
55. C
Note: The cells form a small cluster and they have irregular nuclei and vacuolated cytoplasm. The nuclei are larger than that of adjacent intermediate squamous cells. The cytoplasmic vacuoles contain neutrophils which is a characteristic feature of atypical endometrial cells.
56. C.
Note: The cell in the center is densely keratinized with orangeophilic cytoplasm, which is a clue to the diagnosis of squamous cell carcinoma. The cells are large with irregular hyperchromatic nuclei, one with mitosis. The detached and fragmented orangeophilic cytoplasm (arrow) and granular debris (arrowhead) in this image are also features of invasive squamous cell carcinoma.
57. A.
Note: Cytomorphologic changes associated with IUD effect include vacuolated glandular cells (as shown here) and small dark cell with scant cytoplasm. The vacuolated glandular cells of IUD effect may be indistinguishable from cells of adenocarcinoma especially those in endometrial adenocarcinoma. Diagnosing endometrial adenocarcinoma should be prudent in a woman with IUD use; sometimes a repeat Pap after removal of the IUD may be recommended.
58. D.
Note: The image shows a group of koilocytes with enlarged hyperchromatic nuclei, perinuclear halos with condensed rim and irregular nuclear membrane. These cells are in contrast to the adjacent normal intermediate squamous cells which have smaller nuclei and yellow glycogen in the cytoplasm.31
59. D.
Note: Cells are arranged in hyperchromatic and crowded groups. Cells are columnar in shape and contain dark elongated nuclei with inconspicuous nucleoli. There is “feathering” at the periphery of the group. These are characteristic features for AIS.
60. E.
Note: Tumor cells form a three-dimensional group and have enlarged nuclei (compare to the adjacent nuclei of normal intermediate squamous cells). Tumor cells have abundant vacuolated cytoplasm and intracytoplasmic neutrophils—all of which are features of endometrial adenocarcinoma.
61. C.
Note: The arrow points to elongated rods of Actinomyces sp. which are commonly associated with IUD use.
62. A.
Note: The perinuclear halos shown here are small and represent inflammatory halos associated with infection, such as Candida albicans or Trichomonas vaginalis infection.
63. C.
Note: The smear contains two groups of metaplastic squamous cells. While some cells have round nuclei with smooth nuclear membrane representing normal metaplastic squamous cells, others have mildly enlarged nuclei (arrow) with nuclear grooves and scant cytoplasm, features concerning for HSIL. However, the changes are not sufficient for a diagnosis of HSIL and fit better in the category of atypical squamous cells cannot exclude HSIL (ASC-H).
64. A.
Note: The smear shows a three-dimensional group with a typical “double contour” appearance of benign exfoliated endometrial cells—an outer layer of glandular cells surrounding an inner layer of condensed stromal cells.
65. D.
Note: The malignant tumor cells are columnar in shape and form a glandular-like structure. The background is clean. In light of the clinical history, the findings are most consistent with metastatic colonic adenocarcinoma.
66. E.
Note: Cytoplasmic melanin pigment is an important diagnostic clue in this case.
67. B.
Note: These cells with glycogenated perinuclear halo are called navicular cells. Koilocytes are HPV infected cells; clue cells are squamous cells covered by coccobacilli; corn flake cells represent an air-drying artifact; tadpole cells are elongated keratinizing cells commonly seen in squamous cell carcinoma.
68. A.
Note: The cells show the characteristic changes induced by radiation, including cytomegaly (large nucleus and abundant cytoplasm), nuclear and cytoplasmic vacuoles and polychromasia, prominent nucleoli.
69. D.
Note: The cells show typical features of HSIL: high N/C ratio, hyperchromasia and coarse granular chromatin.
70. E
Note: In this figure the arrow shows keratinizing elongated squamous cells (tadpole cells) associated with a background of granular debris (tumor diathesis), characteristic of keratinizing SCC.
71. B.
Note: The cells show mildly enlarged nuclei, mild hyperchromasia, slightly irregular nuclear membrane and abundant cytoplasm (normal nuclear/cytoplasmic ratio), features qualitatively insufficient for a diagnosis of a SIL lesion; hence the diagnosis of ASCUS. The diagnosis ASC-H is made when some of the cells have a high nuclear/cytoplasmic ratio concerning for HSIL.
72. C.
Note: The cells in this hyperchromatic crowded group (HCG) have high nuclear/cytoplasmic ratio and hyperchromatic nuclei. This hyperchromatic syncytial group is characteristic of squamous cell carcinoma in-situ (CIS, HSIL). LSIL cells have moderate amount of cytoplasm. Parabasal squamous cells have a more flat sheet arrangement with less nuclei crowding and less nuclei hyperchromasia. Benign endometrial cells usually form smaller three-dimensional groups with cells smaller and less nuclear hyperchromasia. Endometrial adenocarcinoma cells have vacuolated cytoplasm and prominent nucleoli.
73. B.
Note: Compare to the hyperchromatic crowded group (HCG) shown in the previous case, this group has a more flat sheet arrangement with less crowding of nuclei. Cells have moderate amount of cytoplasm and less nuclei hyperchromasia. These features support the interpretation of parabasal squamous cells in this smear.
74. A.
Note: This is another example of hyperchromatic crowded group (HCG). Compare this image to the previous two images! This hyperchromatic crowded group is a three-dimensional group composed of cells with small nuclei (same size as the adjacent intermediate squamous cells). Some nuclei are bean-shaped, which is characteristic of endometrial cells. Marked hyperchromasia as in HSIL is not present.32
75. B.
Note: The cells in this three-dimensional group have enlarged nuclei with vesicular chromatin. The cytoplasm is vacuolated and contains intracytoplasmic neutrophils. All findings are characteristic of endometrial adenocarcinoma.
76. B.
Note: This figure shows a group of adenocarcinoma cells. Compare to the endometrial adenocarcinoma in the previous image, cells in this group have prominent macronucleoli and granular cytoplasm-features more characteristic of endocervical adenocarcinoma.
77. B.
Note: These cells have an organized arrangement with elongated and hyperchromatic nuclei without nucleoli, features characteristic of atypical endocervical cells.
78. D.
Note: These cells have a flat sheet arrangement and show features characteristic of radiation changes: cytomegaly (large cells with big nuclei and abundant cytoplasm) and cytoplasmic vacuoles.
79. C.
Note: This smear shows clusters of small blue cells with hyperchromatic nuclei, scant cytoplasm, and nuclear molding, characteristic of small cell carcinoma. The tumor morphology resembles that of the lung small cell carcinoma. Small cell carcinoma of the cervix is commonly associated with HPV type 18, and it is a highly aggressive tumor with early development of distant metastases.
80. B.
Note: The Pap smear shows normal squamous cells and Trichomonas vaginalis (in the center of the image). The proper follow-up screening is to repeat Pap smear in 3 years (or Pap and HPV co-testing in 5 years).
81. C.
Note: The image shows hyperchromatic spindle cells associated with apoptosis and necrosis suggestive of a malignant neoplasm with spindle cell morphology. Positive stains for CD10 and WT-1 are supportive of a diagnosis of endometrial stromal sarcoma.
82. D.
Note: The image shows a group of HSIL cells. When the follow-up colposcopy and endocervical sampling revealed no lesion, the recommended step includes repeat Pap and HPV contesting in 12 and 24 months; or diagnostic excision procedure; or review of cytologic, histologic and colposcopic finding. (J Low Genit Tract Dis. 2013;17(5):S1-S27).
83. E.
Note: The clean background in this image supports a diagnosis of metastatic breast carcinoma.
84. B.
Note: The cells are columnar in shape and have enlarged and hyperchromatic nuclei. The key features are the terminal bar and cilia which are characteristic of tubal metaplasia.
85. E.
Note: The image shows a hyperchromatic crowded group, orangeophilic keratin debris, and an elongated dyskeratotic squamous cell on the top of this image. These features are characteristic of keratinizing squamous cell carcinoma.
86. C.
Note: The image shows a cohesive group of hyperchromatic small cells. Differential diagnosis includes HSIL small cell type versus neuroendocrine carcinoma small cell type. The confirmatory immunohistochemical stain is synaptophysin. Stains for Pan-cytokeratin and p16 are positive in both HSIL and small cell carcinoma (both lesions are associated with HPV infection). Both lesions are negative for CD45 and S-100.
87. A.
Note: This image shows a group of squamous cells in a flat sheet arrangement with streaming and overlying inflammation. This is typical of repair which is a benign reactive condition. No specific follow-up management is needed. The patient can be followed with routine screening including repeat Pap in three years or Pap and HPV co-testing in five years.
88. C.
Note: The image shows mixed population of lymphocytes and a tangible-body macrophage, features characteristic of follicular cervicitis.
89. B.
Note: The group of cells in the center of the image is loosely cohesive. Cells are small and have high nuclear to cytoplasmic ratios. The background is clean. Negative stains for p63 (positive in HSIL), p16 (positive in HSIL and small cell carcinoma), SOX-10 (positive in melanoma), and e-cadherin confirm the diagnosis of metastatic lobular carcinoma. Endometrial adenocarcinoma cells are bigger and have vacuolated cytoplasm with a bloody necrotic background.
90. D.
Note: These cells have enlarged nuclei, vesicular chromatin, mildly irregular nuclear membrane, prominent nucleoli, and vacuolated cytoplasm, mimicking adenocarcinoma. If there is a history of IUD use, interpretation of these cells should be cautious. Clinical correlation and repeat Pap after removal of IUD should be considered.33
91. E.
Note: These structures are psammoma bodies. Presence of psammoma bodies on a Pap smear suggests metastatic serous borderline or malignant neoplasm of ovary or fallopian tube.
92. D.
Note: The cells are of metaplastic cell size; some have irregular nuclear membrane. The overall features are concerning but not sufficient for a definitive diagnosis if HSIL. Therefore ASC-H is the best interpretation of this image.
93. A.
Note: This image depicts atrophic vaginitis showing parabasal/metaplastic squamous cells admixed with inflammation. The cells have round nuclei, smooth nuclear membrane and dense cytoplasm.
94. D.
Note: The image shows a multinucleated giant cell with cytomegaly, cytoplasmic vacuoles and polychromasia. These are features of radiation changes.
95. D.
Note: The image shows a crowded group of cells. The cells have enlarged nuclei and prominent nucleoli which are characteristic of adenocarcinoma. The positive HPV test supports a diagnosis of endocervical adenocarcinoma.
96. C.
Note: The recommend follow-up for a pregnant woman with HSIL on cytology is colposcopic examination. Endocervical curettage in pregnant women is unacceptable. A diagnostic excisional procedure is recommended only if invasion is suspected. Unless invasive cancer is identified, treatment is unacceptable.